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Please print or type. (Form desiqned for use on elite (12-Ditc., _oewriter.)
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<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number 6—; 91
<br />. age 1 of
<br />3. Emergency Respons e_ • '
<br />anifest Tracking
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<br />Number
<br />WASTE MANIFEST
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<br />483-,,P 19 17000971169
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<br />5. Generator's Name and Mailing Address Generator's Site Address (ff different than mailing address)
<br />Ceti Navy, VAsw StrstLe
<br />`S,3n. Joagi fk Cmse,; sow Wie Cirty, F"0 &,r !910 1331 Eaxt rumor Road
<br />%1.mkork, CA 96'AI Loch, CA 0240
<br />Generator's Phone: 2W 468` R_ AT-IrM K.wrtwo A.inidt"o
<br />6. Transporter 1 Company—Name U.S. EPA ID Number
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<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />U.S. EPA ID Number
<br />U r f 'r is t S
<br />Gca ntsvib, UT, 84129 `
<br />Facility's Phone: MAII
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<br />9a,
<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />10. Containers
<br />11. Total
<br />12. Unit
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<br />and Packing Group (if any))
<br />Quantity
<br />Wt.Nol.
<br />13. Waste Codes
<br />No.
<br />Type
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<br />14. Special Handling Instructions and Additional Information + IFT00M2
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<br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged.
<br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true.
<br />Generator's fferor's Pnnted yped Name Signqture Month D7y_ Year
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<br />16. International Shipments
<br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:
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<br />Transporter signature for exports only): Date leaving U.S.:
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<br />17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printedrryped Name Signature Month Day Year
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<br />Transporter 2 Printed/Typed Name Signature Month Day Year
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<br />18. Discrepancy
<br />18a. Discrepancy Indication Space ❑ 0uantit y El Type El Residue El Partial Rejection EJ Full Rejection
<br />Manifest Reference Number:
<br />18b. Alternate Facility (or Generator) U.S. EPA ID Number
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<br />Facility's Phone:
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<br />18c. Signature of Alternate Facility (or Generator) Month Day Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />1.
<br />2.
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br />Printed/Typed Name Signature Month Day Year
<br />ti- ro tsiuu-ct (Kev. s-ub) vrevxous editions are obsolete. GENERATOR'S INITIAL COPY
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